Original Article
Effect of Training Turning Activity along with Cognitive Task on
Balance Performance of Elderly Individuals
Jagriti Sharma*#, Sandeep Singh**##
Abstract
Background and Objective: Falls and falls related injuries are leading cause of
morbidity and mortality in elderly that significantly impair their functional independence.
Decreased balance and gait performance, secondary to decline in strength, cognition,
somatosensation, visual and vestibular function are being held as major factor for falls in
elders. Recent studies have shown that most of falls sustained by elderly are during
steering activities like turning while walking. Present study was undertaken to investigate
the effect of teaching steering activity along with cognitive exercise on balance and gait
performance in elderly.
Methodology: A sample of 30 elderly, aged between 65-85 years, were included in study
and were equally divided in to 2 groups i.e. Group A (control: n=15) and Group B (study
patients: n=15), respectively. Group A received standard balance exercise training whereas
Group B received balance exercises that also included turning activity training with
concurrent cognitive task for 4 weeks. Outcome measures included the Berg Balance Scale
(BBS), Dynamic Gait Index (DGI), Timed Up and Go Test (TUGT), 180o Turn time and Step
Number in 180o turn time during TUGT were measured in both pre and post 4 weeks of
intervention.
Results: Post 4 weeks of intervention, Group B showed significant improvement in BBS
(t= 15.04), DGI (t= 18.50), TUGT (t= 8.51), 180o Turn time (t= 8.28), Step Number in 180o
turn (t= 7.24). Similarly Group A also showed significant improvement for scores of BBS
(7.63), DGI (13.22), TUGT (4.23), Step Number (3.05) except for 180o Turn time where nonsignificant differences were found (t= 1.89). Further, inter-group analysis demonstrated
that Group B exhibited greater improvement than Group A in scores of BBS (t= 2.29), DGI
(t= 4.36), TUGT (t= 3.99), except for Step Number in 180 degree turn (t= 1.58).
Conclusion: The present study concludes that inclusion of concomitant training of turning
activity and cognitive task in the balance exercise program for elderly is more efficacious.
Key words: Falls, balance training, turning difficulty, steering activity.
(Journal of The Indian Academy of Geriatrics, 2015; 11:23-28)
Introduction
Balance is a ffundamental skill which is
important for the safe performance of many
*Clinical Physiotherapist, **Assistant Professor,
#Department of Physiotherapy, Deen Dayal Upadhaya
Zonal Hospital, Shimla; ##Department of
Physiotherapy, Punjabi University, Patiala
activities that acquiesce older people to remain
independent in their community.1 As the individual
ages, there is deterioration in balance systems that
exert negative impact on the performance of multitasking ability of individual in indoor and outdoor
and this is further accentuated in elderly when they
are faced with tasks requiring dividing attention
and one of such task is walking or turning in a
crowd or on a busy road crossing.2,3
24
Journal of The Indian Academy of Geriatrics, Vol. 11, No. 1, March, 2015
Turning is now predominantly identified in
episodes of falling in mobility impaired population
and disruption of turning control can lead to
multiple falls in older individuals.4,5 Turning is one
of the fundamental components of mobility
requiring “higher cognitive and attention functions
(CNS) to make anticipatory postural muscle
adjustments, decelerate the forward motion,
coordinate axial body-segment reorientation to the
new direction of travel, and maintain dynamic
balance within the base of support while continuing
the ongoing step cycle”.6,7 Approximately 35-45
steps in daily activities have been associated with
turning.8 Staggering during turning activity have
been associated with high risk of falls, ultimately
leading to hip fractures and these are the sixth
cause of death among patients aged over 65.9-11
Elderly individuals use step strategy, with longer
turn duration and greater number of turn steps
while changing the direction and walk significantly
slower than the young adults when they face
turning in their travelling pathway.12-14
Most of balance training programs undertaken aim at improving functional mobility of older
adults by mainly training single task or dual task
activities in straight line but training specifically
‘steering’ activities like that of turning is lacking in
most of them. There is need to investigate the effect
of teaching steering activity along with cognitive
exercise.
Material and Methods
Sample: Thirty elderly including both males
and females aged between 65-85 years were
recruited in study. Subjects who were independent
in ambulation and Activities of Daily Living (ADLs)
but having history of fall, having balance and gait
difficulty as depicted by Berg Balance (BBS) Score
between 35-48, Dynamic Gait (DGI) Index score
between 15-20, Timed Up and Go Test (TUGT)
score greater than 10, having difficulty in turning
as indicated by turn time during 180o turn in TUGT
and number of steps taken during 180o turn in
TUGT, were included in the study. Subjects
exhibiting balance impairment other than age
related changes, marked musculoskeletal impairment, history of any injury/surgery of back or lower
limb and subjects who had marked difficulty in
understanding and comprehension or taking
medications affecting equilibrium and balance were
excluded from study. Informed written consent
prior to participation in study was obtained from
each participant and they were explained in detail
about the nature of the study.
Ethical approval: Study was approved by
Ethics Committee of Department of Physiotherapy,
Punjabi University, Patiala.
Design: This study was experimental in
nature with pre and post test design. Participants
were randomly allocated to two groups i.e. Group A
(n=15) age (77.73 ± 4.41) years and Group B(n=15)
age (76.4 ±5.35) years respectively (Table 1).
Baseline measurement of outcome measures i.e.
Berg Balance Scale (BBS)15, Dynamic Gait Index
(DGI)16, Timed Up and Go Test (TUGT) 17, Total
TUG time, 180o turn time, Number of steps in 180o
turn was taken for each participant prior to
commencement of training and then again at the
end of four weeks of intervention.
Table 1. Demographic details and baseline measurements of participants in two groups
Demographic
Age
Mean ±
BMI
SD
Mean ±
SD
Group A (n = 15)
77.73
±
4.41
25.33 ± 1.36
Group B (n = 15)
76.4
± 5.35
25.3 ± 1.60
Intervention: Group A performed standard
balance exercises. Balance training included
exercises- Standing on firm surface with feet apart,
heel stand, toe stand, marching on firm surface,
semi tandem stand, walking forward and backward
with normal base of support.18 Group B performed
balance exercises same as in Group A but with more
emphasis on turning activity and concurrent
cognitive task. Exercises included for this group Standing on firm surface with feet apart, heel stand,
toe stand, marching on firm surface, semi tandem
stand, walking forward and backward with normal
base of support, turn 360 degree on a circle marked
on floor along with cognitive task, turn around
obstacles with normal base of support, turn around
obstacles in tandem walk with concurrent cognitive
task, walk and sudden turn on verbal command,
walking in a figure-of-eight marked on floor with
concurrent functional motor task and cognitive task
(naming words, counting backwards, serial
subtraction of 3, spelling words backwards).18-22
Each of these tasks was performed for 5 repetitions.
The difficulty level of exercise was increased
gradually, with the goal being set just above the
patient’s ability level to perform it. Rest intervals
were given whenever required for the total of 5
minutes in one treatment session. The intervention
was given for 4 weeks, everyday regularly for 4
days a week under supervision of researcher, rest 3
days of week at home. Subjects were instructed to
perform these exercises once a day. In this way
session lasted for 45 minutes to 60 minutes. 5-10
Effect of Training Turning Activity along with Cognitive Task...
25
minutes of warm up and cool down was performed
by the subjects before and after the exercises
respectively. At the end of the four weeks period,
participants were re-tested on the same balance
and gait tests used in the pre test session.
Table 3. The intra-group comparison of BBS, DGI,
TUGT, Turn time, Step No. of pre
and post-intervention in both groups (n =
15 each group).
Data Analysis: All statistical analysis was
done using Microsoft Excel 2008. Mean and
Standard Deviation (SD) were used to prepare
summary statistics. Paired‘t’-test and unpaired ‘t’test was used for intra-group and inter-group
analysis respectively. Results were calculated by
using 0.05 level of significance.
Scales Group
Results
BBS
DGI
Pre-intervention BBS, DGI, TUGT, Turn time
during TUGT, and Step No. during TUGT showed
no significant difference and proves the preintervention group homogeneity (Table 2). Pre and
post-intervention comparison for BBS, DGI, TUGT,
Step number in 180o Turn did shows significant
difference whereas pre and post-intervention scores
of 180o Turn time during TUGT showed significant
difference only for group B (Table 3, Fig 1). Further
comparison of improvement scores (inter-group
analysis) showed significant difference for BBS,
DGI, TUGT between group A and group B. Intergroup analysis for Step No. in 180o turn showed no
significant difference between group A and group B
(Table 4, Fig 2).
TUGT
Turn
time
Step
No.
Preintervention
value
Post‘t’ value
intervention
value
(Mean ± SD)
(Mean ± SD)
Group A
41.87 ± 3.27
44.60 ± 3.58
Group B
42.93 ± 4.40
46.67 ± 4.42 15.04*
Group A
17.60 ± 2.03
19.27 ± 1.83 13.22*
Group B
17.73 ± 2.02
20.20 ± 1.86 18.50*
Group A
14.84 ± 2.79
13.82 ± 2.23
4.23*
Group B
14.64 ± 3.62
12.06 ± 3.19
8.51*
Group A
3.56 ± 1.08
3.38 ± 1.02
1.89NS
Group B
3.64 ± 1.12
2.47 ± 1.13
8.28*
Group A
4.20 ± 0.68
3.80 ± 0.77
3.05*
Group B
4.27 ± 0.59
3.27 ± 0.46
7.24*
*significant; P<0.05
Table 4. The comparison of improvement scores
(inter-group analysis) of BBS, DGI,
TUGT, Turn time during 180 degree
turn, Step No. in 180 degree turn after 4
weeks of intervention between Group A
and Group B.
Scales
Fig. 1. The comparison of mean values of pre and postintervention scores of BBS, DGI, TUGT, Turn time and
Step No. for group A and group B.
Table 2. The Pre-intervention group comparison
between Group A and B
7.63*
Group A
Group B
‘t’ value
(Mean ± SD)
(Mean ± SD)
BBS
2.73 ± 1.39
3.78 ± 0.96
2.29*
DGI
1.67 ± 0.49
2.47 ± 0.52
4.36*
TUGT
1.64 ± 0.93
2.58 ± 1.17
3.99*
Step No.
0.4 ± 0.50
0.1 ± 0.53
1.58NS
*Significant; P<0.05
Control Experimental
(Group A)
(Group B)
Scales
Mean ± SD
Mean ± SD
t’ value
BBS
41.86 ± 3.27 42.93 ± 4.39
0.75NS
DGI
17.6 ± 2.02 17.73 ± 2.01 0.18 NS
TUGT
14.84 ± 2.78 14.64 ± 3.61 0.16 NS
Turn time during TUGT 3.55 ± 1.07
3.64 ± 1.12
0.21 NS
Step No. in 180º Turn
4.26 ± 0.59
0.28 NS
4.2 ± 0.67
NS = Non-Significant; t(28, 0.05) ≤ 2.048
Fig. 2: The comparison of improvement scores (intergroup analysis) of BBS, DGI, TUGT, Step No. in 180o
turn after 4 weeks of intervention between Group A and
Group B
26
Journal of The Indian Academy of Geriatrics, Vol. 11, No. 1, March, 2015
Discussion
Turning is of particular importance in older
adults as falls and fall related injuries are eight
times more common during turning than straight
walking.9,10,24 Major morbidity of falls in elderly
includes hip and other fractures that require
prolonged bed rest or hospitalization. Most of
Balance-Gait
programs
incorporate
training
straight-ahead balance and gait activities while
specifically teaching turning component of
locomotion is largely missing in them. Present
study was undertaken to investigate the effect of
training of repetitive turning activity in elderly on
their balance and gait performance. As a motor
task, turning is challenging task as it always
requires some amount of cognitive process
therefore, participants were made to perform
turning activity along with cognitive tasks.14
Results of the present study depict that both
control (Group A) as well as experimental (Group B)
group
improved
significantly
in
balance
performance of functional tasks after 4 weeks of
intervention as indicated by significant increase in
mean value of post BBS scores. The findings of the
present study are in accordance with the studies by
Harada et al (1995), Steinberg et al (2003) and Nitz
and Choy (2004) where authors have significant
improvement in BBS scores after balance
training.18,26,27 They ascribed this to the effect of
specific and individualized balance intervention
program. In another study by Steadman et al
(2003), significant post exercise improvement in
BBS scores was observed in both intervention group
versus control group.28 They also observed that
independent of strategy, both the groups
significantly improved in balance and mobility
while
intervention
group
showed
greater
improvement in increased confidence in walking
outdoors and indoors.
Similar findings were observed in present
study for performance of gait in both experimental
and control group after 4 weeks of intervention. The
results of present study are in agreement with
study of the Shumway-Cook et al (1997) on older
adults where both exercising groups showed
improved gait performance with reduction in fall
risk (indicated by significant improvement on DGI,
Tinetti mobility test, 3 minute walk test scores) as
compared with control group.29
These improvements in performance of
balance and gait (improved BBS and DGI scores)
can be accredited to individualized exercise
program which ensured greater adherence of
patient to exercise and more personal care and
supervision of researcher. Further on inter-group
analysis between Group A and Group B, significant
improvement was seen in experimental group on
those items of BBS and DGI which were related to
turning, such as 360 degree turn, 180 degree turn
than control group. This improvement may be
ascribed due to repetitive training of turning
activity and concurrent cognitive task in addition to
the balance exercises for participants in
experimental group. Such task encouraged
participants to turn more easily and in less time as
compared to the control exercise group.
Similar trend in findings was observed in
present study for functional mobility and fall risk
as measured on the TUGT in both control and
experimental groups after 4 weeks of intervention.
These results are in accord with findings of the
Kuptniratsaikul et al (2011) on elderly (with a
history of previous fall).30 In another study
conducted by Madureira et al (2007) significant
improvement in TUGT was seen in elderly who
underwent 12 months balance training of 40 hours
(1 hour/week).31 Further on inter-group comparison,
experimental group showed greater improvement
on TUGT scores than Group A, this can be
accredited to the addition of training turning
activity concurrently with cognitive task that had
helped participants of experimental group to
become more proficient to complete 180 degree turn
in less time.
Turning ability of participants was further
measured by recording time and number of steps
taken in completing 180 degree turn in Timed Up
and Go test (TUGT). Results showed that control
and experimental group decreased their number of
steps in completing 180 degree turn suggesting
improved ability in turning. Whereas turn time
required to complete 180 degree turn during TUGT
decreased significantly only in experimental group.
Morgan et al, had used TUGT along with turn time
and number of steps as a measure of turning ability
and to describe movement characteristics in older
adults and authors believed that these measures
can serve as useful and sensitive indicators of
turning difficulty while walking.20 In the present
study control group showed improvement only in
step number whereas experimental group improved
significantly both in turn time and number of steps
taken for completion of 180 degree turn in TUGT.
Thus it means as a whole turning ability (measured
in terms of number of steps and time taken)
improved in experimental group and this may be
attributed to the addition of concurrent cognitive
task along with motor task (repetitive turning
activity) in real context.
Effect of Training Turning Activity along with Cognitive Task...
Conclusion
The study interprets that inclusion of
repetitive turning activity along with cognitive task
in elderly with balance impairment showed
significant improvement on balance score when
compared with those who received conventional
balance exercises only. It is clear that issue of
balance impairment and falls is complex and multifactorial in elderly persons. The health professionals should be able to recognise and differentiate
these factors to plan and implement appropriate
improvement and overwhelming treatment approach. Important consideration which is surfacing is
role of cognition in maintenance of physical
function. There is need to correctly identify the
cognitive decline so that change in physical activity
is not misinterpreted and to appropriately address
and train physical activities like walking, turning
along with cognitive task so that functional independence of older adults can be maintained at optimal
level.
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